December 20, 2012 Thursday December 2012 SuMo TuWe Th Fr Sa 1 2 3 4 5 6 7 8 9101112131415 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January 2013 SuMo TuWe Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 20 Thursday Daily Task List Arrange By: Due Date 7 am MBU Staff Mtg. 4th Floor Team Room 8 00 L&D Staff Mtg. L&D Unit 9 00 10 00 System Policy Subcommittee Mtg. Executive Conf.Room 6202 - USS Tower, 62nd Floor Dickson, Corinne 11 00 12 pm 1 00 Notes 2 00 3 00 L & D Staff Mtg. L&D Unit Dickson, Corinne MBU Staff Mtg. 4th Floor Team Room 4 00 Daily Care Management Debriefing; CR_HAM_Courtyard_Conference; Dickson, Corinne 5 00 6 00 Donnelly, James 1 3/9/2015 7:08 AM
Department: MBU 4 th Floor Team Room Meeting Date: December 20, 2012 / 7:00 and 3:00 Culture Item Discussion Form After reviewing your item level results, which item is of particular concern or relevance to this work setting right now due to recent or ongoing events or activities? Hospital Handoffs and Transitions Teamwork Across Hospital Units Non punitive Response to Error Why was this item important to your group? Hospital Handoffs and Transitions: Handoffs are important because it affects patient safety. Information is being missed that is pertinent to patient care. Teamwork Across Hospital Units: Transitions of care between units are important; when we fail to communicate with each other and work collaboratively, important elements of care are missed and patient safety is jeopardized. Non punitive Response to Error: Need to be transparent to learn from mistakes; we all need to be held to the same standards of accountability. What are some specific examples that illustrate how this item reflects your experiences this work setting? Handoffs: Important details about neonates are often not communicated to the MBU staff; some of these details are associated with time dependent elements of care that the MBU is accountable for Poor feeders, infectious diseases concerns, and complex social issues are often not passed on; this leaves the MBU staff in the dark and puts the baby at risk. We care for a lot of prisoners and drug-addicted mom s; these stories are often not communicated to MBU. These complex social issues make bedside report uncomfortable or impossible because family and partners are most often in the room. Consequently, sensitive but important information is not being passed on. Nurses often get around this by giving one report at the bedside and another outside the room this allows for an opportunity to miss vital information. Handoff reports are often incomplete and important information, such as lab work, is left off forcing the MB RN to review the chart as well; this adds to the time required to admit a patient. Patient information is missed most often when census is heavy. General gaps in communication across NICU and L&D to MBU. Teamwork Across Hospital Units: Units across the Women s Hospital do not provide coverage or support for each other. We need a float pool resource to help cover surges. L&D nurses often claim they are too busy to take phone calls to ask about critical patient information. Verbal reports are better than the handoff forms b/c they give nurse s the opportunity to ask questions. Non punitive Response to Error: There are no consequences for an incomplete form so why complete it? Nurses from another unit who have an issue will tell our unit director rather than talk to me. I think we should try to communicate issues at the staff level first before going up the chain of command.
Department: MBU 4 th Floor Team Room Meeting Date: December 20, 2012 / 7:00 and 3:00 Envision an ideal unit. What would it look like if 100% of the respondents in this unit felt positively about this survey item (provide specific behaviors, processes, norms, policies, etc.)? MBU could pull the information from the handoff unit instead of having the form completed once the patient arrives. This would allow for verbal handoff and the opportunity to ask questions. Create automated summaries. The L&D Gen View is a great form but is often not completed by nursing and physicians. Actionable Items: MBU would like the census for the next day from L&D for scheduled inductions and sections. This info is helpful for staffing. RNs used to be able to pull this information from Soarian but cannot retrieve it from Cerner. Cross training between MBU and L&D would be helpful. Handoff practice needs revised; it is not working. Person(s) Responsible: Dianna Lindsey, Emma Mack, and Nell Nipper Follow up Date: February 1, 2013 Long Term Items: Resource/Float Pool for WH
CULTURE OF SAFETY SURVEY 2012 Mom Baby / Labor and Delivery
Purpose and Scope of Survey Measure house-wide to obtain a baseline for each unit s perception of safety within their unit culture of the unit Use data-driven approach that moves caregivers from reacting and responding to being proactive and prospective Prioritize interventions based on vulnerability and risk Support frontline caregivers by rewarding strong work settings with recognition and ensure weaker work settings have support and accountability 2
Eligible Respondents Have worked in the work setting for at least four weeks at the time of the start of the survey (April 30 th June 4 th ) Worked 20 hours / week in that work setting Physician must admit 2 patients per month and admits the majority of his/her patients to that work setting Surgeon must perform at least 5 procedures per month in his/her work setting OBGYN must perform at least 5 deliveries per month in his/her work setting Those on FMLA at the time of the survey were not surveyed 3
About The Survey All UPMC Hospitals participated in the survey UPMC Hamot Surveys: Paper based (5 point system: disagree strongly, disagree slightly, neutral, agree slightly, agree strongly, NA) 42 units were surveyed A total of 1575 surveys were distributed A total of 1471 were completed Compliance Rate of 93.4% UPMC Hamot achieved the highest response rate in the System CONGRATULATIONS! 4
5 Housewide Report Card
Housewide - Strengths vs. Opportunities Strengths: 78%: Teamwork within Hospital Units 72%: Supervisor Actions Promoting Safety 67%: Organization Learning & Continuous Improvements 65%: Feedback & Communication about Error 63%: Frequency of Event Reporting 62%: Overall Perception of Safety Opportunities: 48%: Teamwork Across Hospital Units 46%: Staffing 35%: Hospital Handoff & Transitions 33%: Nonpunitive Response to Error 6
7 MBU/L&D Report Card
Dept Name - Strengths vs. Opportunities Strengths: 88%: Teamwork within Hospital Units 84%: Supervisor Actions Promoting Safety 80%: Organization Learning & Continuous Improvements 69%: Frequency of Event Reporting 69%: Overall Perception of Safety 67%: Hospital Management Support for Safety Opportunities: 43%: Teamwork Across Hospital Units 43%: Hospital Handoff & Transitions 27%: Non-punitive Response to Error 8
9 Key Focus Areas Non-punitive Response to Error
10 Key Focus Areas Hospital Handoffs & Transitions
11 Key Focus Areas Teamwork Across Hospital Units
Contacts Thank you for your input! Please email or call us for additional ideas or suggestions for improvement. Jim Donnelly 877-4143 Kristin Grande 877-2782 12